«Partnership HealthPlan of California Medi-Cal Member Handbook Together for your Health Our Service Area Del Norte, Humboldt, Lake, Lassen, Marin, ...»
You may be able to use non-medical transportation (NMT) when you are getting to and from a medical appointment related to prenatal care, renal dialysis, outpatient surgery, radiation, chemotherapy, specialty consult services but your medical condition does not require you to use medical transportation such as an ambulance, litter van, or wheelchair van, to get to your appointment. Prior approval is always required. NMT is defined as a taxi, bus, or other public way of getting to your medical appointment.
Members under 21 years may be able to get more services through a national program called Early and Periodic Screening, Diagnosis and Treatment (EPSDT). This includes doctor, nurse practitioner and hospital services. It also includes physical, speech/language, occupational therapies and home health services. Other services it covers are medical equipment, supplies, and devices; treatment for mental health and drug use, and treatment for eye, ear and mouth problems. If you have questions about the EPSDT program, please call Partnership HealthPlan’s Member Services Department.
To ask for NMT services, please call PHC’s Care Coordination Department at (800) 809-1350 at least one business day (Monday-Friday) before your appointment. Or call as soon as you can when you have an urgent appointment. Please have your member ID card ready when you call.
Limits of NMT:
There are no limits on the number of rides to or from medical appointments covered under the EPSDT program. For the other, non-EPSDT services listed above, this service may be discontinued when a member has a history of three (3) or more missed appointments in a calendar year.
What Doesn’t Apply?
NMT does not apply if:
1) an ambulance, litter van, wheelchair van, or other form of NEMT is medically needed to get to a covered service;
2) the service is not covered by PHC. A list of covered services is in this member handbook;
3) requesting reimbursement for gas.
Cost to Member:
There is no cost when transportation is allowed by PHC.
This section of the Handbook talks about services you can get from PHC, State Medi-Cal or Other Programs.
Please read below to see how to use the chart of covered services that starts on the next page.
About the covered services chart The covered services chart lists most services you can get as a PHC Medi-Cal member. The chart
has two columns, for each benefit (row) there are two pieces of information:
Column 1: Benefit name. Benefits are listed in alphabetical order.
Column 2: What is covered. This section lists what the benefit covers and if Prior Approval is needed.
Some services require Prior Approval. Those services will say Prior Approval in the “What is covered” column. Services requiring Prior Approval are covered if they are medically necessary with Prior Approval from your provider or PHC.
Limited benefits These services are listed as “Limited Benefits” in the List of Covered Services Chart in this Section. These benefits are limited to children (up to 21 years of age), and certain groups over 21 years of age. Not everyone will qualify for a Limited Benefit.
Some Limited Benefits have extra coverage through PHC or Health Centers. See Section 3 of this Handbook for more information.
Some of the benefits in the “List of Covered Services Chart” below are only covered if you meet
one of these requirements:
You are under 21 You live in a Skilled Nursing Facility You are pregnant, and the care is needed to keep your baby healthy You have Prior Approval from the Genetically Handicapped Persons Program (GHPP) You have Prior Approval from the California Children’s Services program (CCS) The service is covered by Medicare Part B The service is needed because of an emergency and you get the care in the emergency room Your Home County health office or your Health Center offers the service
If you think you qualify for one of these Limited Benefits and want to know how to access them, call PHC’s Member Services Department at (800) 863-4155 or ask your provider for more information.
Members with limited Medi-Cal Some members have coverage for emergency-only or pregnancy-only. That means that only the benefits for emergency services and pregnancy services in the “List of Covered Services” below applies to members who have “limited” Medi-Cal. All other health care, even if that health care is a Medi-Cal benefit, is not covered by PHC or the Medi-Cal program.
Additional services not included in the “List of Covered Services Chart” If you have questions about a service that isn’t listed in this section, call PHC’s Member Services Department to find out if that service is covered by PHC.
The following is a list of additional services that you may have access to:
Alcohol and Drug Treatment Alpha-fetoprotein Lab Services Childhood Lead Poisoning Case Management Dental Services Directly Observed Therapy (DOT) for Tuberculosis Fabrication of Optical Lenses (for glasses) Home and Community Based Services (HCBS) Waiver Program services Local Education Agency (LEA) services Multi-Purpose Senior Service Program (MSSP) Pediatric Day Health Care Personal Care Services Services in any Federal or State governmental hospital Short-Doyle Mental Health Services Some HIV/AIDS Drugs Some Psychotherapeutic Drugs Specialty Mental Health Services for the treatment of severe mental health conditions Targeted Case Management Services If you have questions about the services listed here or about a service that you can’t find in this Handbook, please call PHC’s Member Services Department for help.
Section 10 – What does Medi-Cal not cover?
Learn about what is not covered by PHC or Medi-Cal.
The list below is for services that are not covered by PHC or by State Medi-Cal:
Services that are excluded from Medi-Cal under state and federal law Same day surgery or hospital admission solely for the purpose of routine circumcision Cosmetic surgery (surgery that is done to change your body to improve how you look) Custodial care. Some custodial care may be covered by State Medi-Cal. For more information about custodial care covered by State Medi-Cal, call your Home County Medi-Cal eligibility office.
Experimental and investigational services Infertility, including reversing sterilization Shots for sports (for adults), work or travel Personal comfort items like a phone, TV or guest tray when you are in the hospital Services that are not medically necessary Mental health services for relationship problems are not covered. This includes counseling for couples or families for conditions listed as relational problems as defined by the current Diagnostic and Statistical Manual of Mental Disorders (DSM).
Services not covered when you have other insurance
If you have another insurance coverage (like Worker’s Compensation, coverage because of an accident, or insurance through your work), PHC will not pay for your health care because your other insurance has to pay first. This is called “Coordination of Benefits.” See Section 13 of this Handbook to learn about Coordination of Benefits.
You can call PHC’s Member Services Department if you have questions about another insurance you might have and how PHC works with your other insurance to make sure you get the health care you need.
Section 11 – Prescription Drugs Learn about our prescription drug benefit and how to get covered drugs.
If your provider thinks you need a prescription drug (medication or medicine) your provider will write you a prescription. Prescriptions are filled by a pharmacy that works with PHC.
Covered and approved drugs are available at no cost to you.
Members with other insurance, like Medicare Part D, may have to pay a co-pay.
What is a pharmacy?
A pharmacy is a provider that fills your prescriptions. PHC works with many pharmacies in the service area, including independent pharmacies, pharmacies in grocery stores and pharmacy chains.
Your Provider Directory lists all of the pharmacies in your Home County and you can go to any of them listed in the provider directory.
If you are ever asked to pay for your medication, call PHC’s Member Services Department. If you have already paid for your prescription see Section 13 of this Handbook for more information.
How to get a prescription filled Choose a pharmacy that works with PHC Bring your prescription to your pharmacy Show the pharmacy your PHC ID card and any other insurance cards you have Make sure your pharmacy knows of any other medications you’re taking, and if you have any allergies to any medicines Ask your pharmacist any questions you may have about your prescription(s)
If you are refilling a prescription you already have, go to a pharmacy listed in your Provider Directory. Some medicines covered by PHC can be filled for 90-days. These medicines are called “maintenance medications” and are drugs that you have to take for a long time. Examples of maintenance medications include drugs for high blood pressure or diabetes.
Ask your provider if you can get a longer supply of maintenance medications.
What is a formulary?
A formulary is a list of drugs that are approved by a PHC committee of providers and pharmacists. These providers and pharmacists meet every three months to review and make changes to our formulary.
Drugs on the formulary are reviewed and picked for their quality, safety, effectiveness and affordability.
Can I use a pharmacy out of the area?
Sometimes, you may have to use a pharmacy outside of our network. You can get a limited supply of your prescription drugs in times like these.
Remember, covered drugs are available at no cost to you.
Drugs not on the formulary If your provider writes you a prescription for a drug not on PHC’s formulary, your provider may need to contact PHC for Prior Approval. Your pharmacy may give you the Generic version of the drug you were prescribed, if the Generic version of the drug is on PHC’s formulary.
If your prescribed drug is not on the formulary and a Generic version of the drug is not available, your pharmacy may contact PHC to submit a request for Prior Approval (also called a Treatment Authorization Request, or TAR).
PHC looks at these requests for Prior Approval within 1 business day (24 hours). PHC may ask the pharmacy or your provider (or both) for more information. Sometimes this process can take a few days depending on how quickly your provider submits this information to PHC.
If the drug is approved, you can get your drug at your pharmacy. If the drug is denied, you have a right to file an appeal. See Section 12 of this Handbook for more information.
Brand Name Drugs and Generic Drugs Generic drugs are drugs that have the same active ingredient as the Brand name version of the drug. Generic drugs are approved for use by the federal Food and Drug Administration (FDA) and usually cost less than Brand name drugs.
Generic drugs must be used unless there is a medical reason why you cannot use the Generic version of the drug. This is called “generic substitution.” PHC’s network pharmacies will dispense Generic drugs even if the prescription they get is for a Brand drug, unless your provider has told the pharmacy to only give the Brand drug. If your provider believes you need to have the Brand version of a drug, Prior Approval is needed from PHC.
What drugs are not covered?
Certain drugs are not covered by PHC. These include:
Drugs from a pharmacy not in PHC’s network, except for drugs needed because of an emergency or out-of-area care Non-formulary drugs, except when you have a Prior Approval from PHC Drugs that are experimental or investigational, except in certain instances of terminal illness. If you have been denied an experimental or investigational drug, you have the right to file an appeal or ask for a State Hearing. To learn more about filing an appeal or asking for a State Hearing, see Section 12 of this Handbook for more information.
Cosmetic drugs, except as prescribed for medically necessary conditions Non-formulary dietary or nutritional products, except when medically necessary or for the treatment of Phenylketonuria Any injectable drug that is not medically necessary Appetite suppressants, except as medically necessary for morbid obesity Compounded medications with formulary alternatives or those with no FDA-approved use Replacement of lost or destroyed drugs no more than two times each year (from January to December) Infertility drugs Emergency contraception (“Plan B”)
You may get emergency contraception drugs from:
Your provider A pharmacy with a prescription from your provider, if you are younger than 17 A pharmacy without a prescription if you are older than 17 A pharmacy not in PHC’s network. If this is the case, you may be asked to pay for this service. PHC will reimburse you if you have to pay for the drug. See Section 13 of this Handbook for more information.
A local Family Planning provider Prescriptions in emergency or urgent situations Your pharmacist can give you an emergency 5-day supply of a medication if you are out of medication or if you were discharged from the emergency room but not put in the hospital.
You should talk to your provider if you got a 5-day emergency supply of medication to get a longer prescription of medication.
If you have Medicare If you have Medicare Part D, or qualify for Part D, you must use your Medicare Part D plan to get your prescriptions covered. You can get Medicare Part D if you have Medicare Part A or Part B.